Classification system
Gartland Classification
Gartland Classification of Supracondylar Humerus Fractures
The Gartland classification grades extension-type supracondylar humerus fractures in children as type I when non-displaced, type II when angulated with the posterior cortex intact, type III when completely displaced with no cortical contact, and type IV when the fracture is unstable in both flexion and extension — a diagnosis that can only be made under fluoroscopy in theatre.
What the Gartland category means
Gartland scores run from 1 to 4, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.
- Non-operative (type I)1–1
Long-arm cast at approximately 90° of flexion, with a radiograph at about a week to confirm alignment is maintained.
- Operative (types II–IV)2–4
Closed reduction and percutaneous pinning for most. Type III is the urgent one; type IV changes the reduction technique rather than the decision to operate.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Anterior humeral line passing through the middle third of the capitellum on the lateral view — consistent with type I | — | Children with an extension-type supracondylar humerus fracture | — | Gartland JJ 1959 |
| Criterion | Intact posterior cortical hinge separates type II from type III | — | Children with an extension-type supracondylar humerus fracture | — | Gartland JJ 1959 |
| Criterion | Instability in both flexion and extension under fluoroscopy defines type IV, which cannot be assigned from static radiographs | — | Children undergoing reduction of a supracondylar humerus fracture | — | Leitch KK 2006 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
The classification applies to extension-type fractures, in which the distal fragment displaces posteriorly. Type I is non-displaced or minimally displaced: the anterior humeral line still passes through the middle third of the capitellum on the lateral radiograph, and the fracture may be visible only as a posterior fat pad sign. Type II is displaced with the posterior cortex intact, so the fragment is angulated but still hinged; the anterior humeral line no longer passes through the middle third of the capitellum. Wilkins subdivided this into IIA, angulation alone, and IIB, angulation with rotational malalignment, because rotation makes a cast unreliable. Type III is complete displacement with no cortical contact, described further as posteromedial or posterolateral by the direction the distal fragment has gone. Type IV, added by Leitch and colleagues, is multidirectional instability from circumferential periosteal disruption, and is defined by the fracture displacing in both flexion and extension under fluoroscopy — it therefore cannot be assigned from static radiographs and is recognised intraoperatively. Flexion-type fractures, in which the distal fragment displaces anteriorly, fall outside the system entirely.
Instrument profile
- Developer
- J. J. Gartland; type IV described by Kellie K. Leitch and colleagues
- Institution
- Jefferson Medical College, Philadelphia, United States
- First published
- 1959
- Items
- 2
- Response format
- Mechanism, then displacement pattern
- Score range
- 1 to 4
- Direction
- Lower score = better
- Completion time
- About 1 minutes
- Age range
- Children, typically 5 to 7 years
- Regions
- Paediatric, Elbow
- Conditions
- Supracondylar humerus fracture, Paediatric elbow fracture, Anterior interosseous nerve palsy, Pulseless hand after elbow injury
- Procedures
- Closed reduction and percutaneous pinning, Open reduction of a supracondylar fracture, Long-arm cast immobilisation, Brachial artery exploration
- Validity
- The type maps directly onto treatment — cast for type I, pin for types II to IV — which is why it has survived unchanged in substance since 1959. It does not predict the neurovascular complications, which follow the direction and energy of displacement rather than the type number.
- Reliability
- Agreement is good for type I versus type III and weakest at the I–II boundary, which turns on where the anterior humeral line crosses the capitellum on a lateral view that is often imperfectly positioned in a distressed child.
When to use the Gartland
Well suited to
- Classifying a paediatric supracondylar humerus fracture to decide between a cast and theatre.
- Communicating urgency in a referral: a type III with an abnormal neurovascular examination is a different call from a type II.
- Documenting the injury in a form that transfers between the emergency department and the operating surgeon.
Limitations and poor fits
- Flexion-type fractures, which the system does not describe and which carry their own reduction difficulties and a higher rate of ulnar nerve injury.
- Adults, in whom distal humeral fractures are classified by the AO/OTA system and treated quite differently.
- As a neurovascular assessment. The type does not record nerve or vascular injury, and a documented examination of each nerve and of hand perfusion before and after any manipulation is a separate and non-negotiable step.
- Assigning type IV preoperatively — it is an intraoperative fluoroscopic diagnosis.
- Other paediatric elbow injuries that mimic it, including lateral condyle fractures, medial epicondyle avulsions and transphyseal separations in infants.
Gartland compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Salter-Harris | 3 | 1–5 | The Salter-Harris classification grades fractures involving the growth plate into five types, from a fracture through the physis alone (type I) to a crush injury of the physis (type V), according to whether the fracture line also involves the metaphysis, the epiphysis, or both. |
| Kocher Criteria | 4 | 0–4 | The Kocher criteria estimate the probability that a child with an irritable hip has septic arthritis rather than transient synovitis, using four independent predictors — non-weight-bearing, fever above 38.5 °C, ESR above 40 mm/hour and white cell count above 12,000 — with predicted probability rising from under 0.2% when none are present to over 99% when all four are. |
| AO/OTA | 3 | 1–3 | The AO/OTA classification gives every fracture an alphanumeric code in which the first digit is the bone, the second the segment and the letter the fracture type — extra-articular, partial articular or complete articular in an end segment, and simple, wedge or multifragmentary in a shaft — so that 32-A is a simple femoral shaft fracture and 43-C a complete articular pilon fracture. |
| Mason | 2 | 1–4 | The Mason classification sorts radial head fractures into four types — non-displaced (I), displaced partial articular (II), comminuted involving the whole head (III), and any radial head fracture accompanied by an elbow dislocation (IV) — and the type broadly separates fractures managed non-operatively from those needing fixation or replacement. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published radiographic classification system. No licence is required.
References
- Gartland JJ. Management of supracondylar fractures of the humerus in children. Surgery, Gynecology and Obstetrics. 1959.
- Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. Treatment of multidirectionally unstable supracondylar humeral fractures in children: a modified Gartland type-IV fracture. Journal of Bone and Joint Surgery (American Volume). 2006.
- Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children: the consequences of pin placement. Journal of Bone and Joint Surgery (American Volume). 2001.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.